Clinical care of vesicoureteral reflux: preventing adoption of a procedure-driven algorithm.

OBJECTIVES: Although minimally invasive procedures have created a groundswell, supportive of early intervention as on expedient alternative to surveillance, we present a patient-driven model of care that weighs risk and benefit for each individual. METHODS: A practice review was performed for the period 2000-2006. The records of all patients diagnosed by, or referred to, our group (three full-time Pediatric Urologists with a regional service population of 1.7 million) were included in on analysis of vesicoureteral incidence, initial management, and surgical approach. RESULTS: During the review period, the incidence of newly diagnosed VUR increased at a rate of 4% per year, with 66% of these accrued from evaluation of prenatal hydronephrosis and asymptomatic siblings of known reflux patients. The number of children with VUR and a significant component of DES also increased over time. During this period of higher case volume, surgical intervention failed to increase significantly but did show a dramatic procedural shift toward minimally invasive techniques for all providers and probable delayed intervention in a substantive number of cases until endoscopic treatment was freely accessible between 2002-2004. CONCLUSION: Our patient-driven model respects current literature and clinical experience, while acknowledging that our understanding is still currently in evolution. As our knowledge grows, from well-designed prospective study, we adopt new techniques and retire archaic practices. At this point in time, however, we find evidence lacking to support adoption of a procedure-driven algorithm in the care of VUR.

Clinical care of vesicoureteral reflux: preventing adoption of a procedure-driven algorithm / Manejo clínico del reflujo vesicoureteral: evitando la adopción de un algoritmo dirigido por el procedimiento

Objectives: Although minimally invasive procedures have created a groundswell, supportive of early intervention as an expedient alternative to surveillance, we present a patient-driven model of care that weighs risk and benefit for each individual. Methods: A practice review was performed for the period 2000-2006. The records of all patients diagnosed by, or referred to, our group (three full-time Pediatric Urologists with a regional service population of 1.7 million) were included in an analysis of vesicoureteral incidence, initial management, and surgical approach. Results: During the review period, the incidence of newly diagnosed VUR increased at a rate of 4% per year, with 66% of these accrued from evaluation of pre-natal hydronephrosis and asymptomatic siblings of known reflux patients. The number of children with VUR and a significant component of DES also increased over time. During this period of higher case volume, surgical intervention failed to increase significantly, but did show a dramatic procedural shift toward minimally invasive techniques for all providers and probable delayed intervention in a substantive number of cases until endoscopic treatment was freely accessible between 2002-2004. Conclusion: Our patient-driven model respects current literature and clinical experience, while acknowledging that our understanding is still currently in evolution. As our knowledge grows, from well-designed prospective study, we adopt new techniques and retire archaic practices. At this point in time, however, we find evidence lacking to support adoption of a procedure-driven algorithm in the care of VUR (AU)

Objetivo: Aunque los procedimientos mínimamente invasivos han creado un clamor popular apoyando la intervención temprana como una alternativa conveniente a la observación, presentamos un modelo de manejo centrado en el paciente, que valora la relación riesgo-beneficio en cada individuo Métodos: Realizamos una revisión de la práctica clínica en el periodo 2000-2006. Las historias clínicas de todos los pacientes diagnosticados por nuestro grupo o derivados a él (tres urólogos pediátricos con dedicación completa, con una población de referencia de 1,7 millones de habitantes) se incluyeron en un análisis de la incidencia de reflujo vesicoureteral, el manejo inicial y el abordaje quirúrgico. Resultados: Durante el periodo de revisión, la incidencia de reflujo vesicoureteral de nuevo diagnóstico aumentó con un ritmo del 4% anual, con un 66% de los casos provenientes de la evaluación de hidronefrosis prenatales y hermanos asintomáticos de pacientes con reflujo conocido. El número de niños con reflujo vesicoureteral y un componente significativo de síndrome de eliminación disfuncional también ha aumentado con el tiempo durante este período de mayor volumen de casos; el número de intervenciones quirúrgicas no ha aumentado significativamente, pero se ha visto un cambio dramático de procedimientos hacia técnicas mínimamente invasivas y un probable retraso de la intervención en un número sustantivo de casos hasta que el tratamiento endoscópico fue libremente accesible entre 2002-2004. Conclusiones: Nuestro modelo dirigido al paciente respeta la literatura actual y la experiencia clínica, y a la vez reconoce que nuestro conocimiento hoy está todavía en evolución. A medida que crece nuestro conocimiento, a partir de estudios prospectivos bien diseñados, adoptamos nuevas técnicas y retiramos las viejas prácticas. En este punto del tiempo, sin embargo, encontramos una falta de evidencia para apoyar la adopción de un algoritmo dirigido por el procedimiento en el cuidado del reflujo vesicoureteral (AU)

A multi-institutional randomized controlled trial of adjuvant Web-based teaching to medical students.

PURPOSE: To investigate the impact of an adjuvant Web-based teaching program on medical students' learning during clinical rotations. METHOD: From April 2003 to May 2004, 351 students completing clinical rotations in surgery-urology at four U.S. medical schools were invited to volunteer for the study. Web-based teaching cases were developed covering four core urologic topics. Students were block randomized to receive Web-based teaching on two of the four topics. Before and after a designated duration at each institution (ranging one to three weeks), students completed a validated 28-item Web-based test (Cronbach's alpha = .76) covering all four topics. The test was also administered to a subset of students at one school at the conclusion of their third-year to measure long-term learning. RESULTS: Eighty-one percent of all eligible students (286/351) volunteered to participate in the study, 73% of whom (210/286) completed the Web-based program. Compared to controls, Web-based teaching significantly increased test scores in the four topics at each medical school (p < .001, mixed analysis of variance), corresponding to a Cohen's d effect size of 1.52 (95% confidence interval [CI], 1.23-1.80). Learning efficiency was increased three-fold by Web-based teaching (Cohen's d effect size 1.16; 95% CI 1.13-1.19). Students who were tested a median of 4.8 months later demonstrated significantly higher scores for Web-based teaching compared to non-Web-based teaching (p = .007, paired t-test). Limited learning was noted in the absence of Web-based teaching. CONCLUSIONS: This randomized controlled trial provides Class I evidence that Web-based teaching as an adjunct to clinical experiences can significantly and durably improve medical students' learning.

Results of a 2-year multicenter trial of endoscopic treatment of vesicoureteral reflux with synthetic calcium hydroxyapatite.

PURPOSE: With no FDA approved material available for endoscopic treatment of vesicoureteral reflux, in 2001 we began a prospective multicenter trial of synthetic calcium hydroxyapatite as a subureteral bulking agent in children with traditional indications for surgical repair. MATERIALS AND METHODS: A total of 98 patients (155 ureters) with grades II to IV reflux were enrolled at 10 sites in the United States to obtain 86 patients with completed protocol end points at 3 months. Of the 86 patients 74 underwent renal and bladder ultrasonography, blood count and serum chemistry analysis, and VCUG at 1 year. A total of 46 patients (47%) completed 2-year study end points, including VCUG. RESULTS: At 1 and 2 years 24 of the 74 patients (32%) were cured. Ureteral cure rates were 46% and 40% at 1 and 2 years, respectively. With 35 patients treated and 85% compliance with the required 2-year VCUG the primary center achieved 2-year cure rates of 66% of patients and 72% of ureters. CONCLUSIONS: Synthetic calcium hydroxyapatite is a safe, durable and effective material for endoscopic treatment of VUR. Increased experience with the injection of synthetic calcium hydroxyapatite yields improved results.

Testicular torsion: direction, degree, duration and disinformation.

PURPOSE: We reviewed and contrast with the literature the cumulative clinical experience at our pediatric urological division in the last 20 years with managing testicular torsion, focusing specifically on the direction and degree of testicular torsion and the duration of symptoms before presentation. We also addressed the incidence of gastrointestinal symptoms, role of manual detorsion, residual torsion and incidence of atrophy. MATERIALS AND METHODS: We reviewed the medical records of 200 consecutive males 18 months to 20 years old who underwent surgical exploration by a pediatric urologist for a diagnosis of testicular torsion between 1980 and 2000. RESULTS: Of 186 nonelective explorations symptoms were localized to the left side in 52% and to the right side in 48%. Information on the direction and degree of testicular rotation was available in 162 of 186 cases (87%) and anticipated medial rotation occurred in only 108 (67%). Lateral rotation in 54 of 162 cases (33%) occurred in 28 of 84 (33%) with left torsion and in 26 of 78 (33%) with right torsion. A median of 540 degrees of torsion (range 180 to 1,080) was noted in the 70 orchiectomy cases (38%) and a median of 360 degrees (range 180 to 1,080) was noted in the 116 salvaged testes (62%). Manual detorsion was attempted in 53 orchiopexy cases with residual torsion in 17 (32%). Testicular atrophy developed in 27% of the patients. CONCLUSIONS: The traditional teaching that testicular torsion occurs primarily in the medial direction is misleading since in a third of cases it occurs in the lateral direction. While manual detorsion should be guided by response and return of normal anatomy, surgical exploration remains necessary since residual torsion still poses a risk to testicular viability. Long-term followup is warranted to assess the true incidence of subsequent atrophy after the management of acute testicular torsion.

Bladder calculus formation and urinary retention secondary to perforation of a normal bladder by a ventriculoperitoneal shunt.

Urinary retention due to bladder calculus formation is unusual in the pediatric population. This case report describes a rare sequence of events in which a bladder stone formed secondary to the erosion of a ventriculoperitoneal shunt through a normal bladder wall. A review of the literature is included.